MEDICARE: AFFORDABLE SMILES OF GRETNA, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1023674777
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	AFFORDABLE SMILES OF GRETNA, LLC

Provider Business Mailing Address
First Line	:	400 LAPALCO BLVD STE B
Second Line	:
City	:	GRETNA
State	:	LA
Zip	:	70056-7372
Country	:	US
Telephone Number	:	504-370-9220
Fax Number	:	504-507-8880

Provider Business Practice Location Address
First Line	:	400 LAPALCO BLVD STE B
Second Line	:
City	:	GRETNA
State	:	LA
Zip	:	70056-7372
Country	:	US
Telephone Number	:	504-370-9220
Fax Number	:	504-507-8880

Authorized Official
Title or Position	:	INSURANCE CREDENTIALING MANAGER
Name	:	MRS. SAMANTHA COATS
Credential	:
Telephone Number	:	504-609-2599

Provider Enumeration Date	:	05/17/2019
Last Update Date	:	02/08/2021

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